Excellence in Optometric Education

John A. McGreal Jr., O.D. Missouri Eye Associates

McGreal Educational Institute

Implementing New & Revised ICD-10 Codes

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John A. McGreal Jr., O.D. ■ Missouri Eye Associates ■ McGreal Educational Institute ■  11710 Old Ballas Rd. ■  St. Louis, MO. 63141 ■  314.569.2020 ■  314.569.1596 FAX ■ Mcgrealjohn@gmail.com

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Review of Changes in ICD-10 2017 ■ Review New & Revised ICD-10 Codes for 2017

–  1,974 new codes –  425 revised codes –  311 deleted codes

■ New reporting for AMD ■ New Reporting for CRVO & BRVO ■ New Reporting for Diabetes ■ New Reporting for Glaucoma Codes ■  ICD-10 Coding Tips ■ Effective Date – October 1, 2016 !!

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Review of Changes in ICD-10 ■  Part B Medicare providers must submit claims with

the most specific ICD-10-CM codes available ■ CMS allowed a one year specificity safe harbor

grace period after implementing ICD-10 2016 last year –  Allowed payment for claims with less specificity

provided the code was from the correct family –  This grace period ends October 1, 2016

■ Most significant changes are in coding diabetes, macular degeneration, retinal vascular disease, & glaucoma –  Staging and laterality added for more detail

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Tabular List Detail ■  Chapter 1 Infectious and parasitic diseases (A00-B99) ■  Chapter 2 Neoplasms (C00-D49) ■  Chapter 3 Diseases of Blood and blood forms (D50-D89) ■  Chapter 4 Endocrine, nutritional, metabolic (E00-E90) ■  Chapter 5 Mental & behavioral (F01-F99) ■  Chapter 6 Nervous system (G00-G99) ■  Chapter 7 Eye & adnexa (H00-H59) ■  Chapter 8 Ear and mastoid (H60-H95) ■  Chapter 9 Circulatory system (I00-I99) ■  Chapter 10 Respiratory system (J00-J99) ■  Chapter 11 Digestive system (K00-K94)

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Tabular List Detail ■  Chapter 12 Skin & subcutaneous (L00-L99) ■  Chapter 13 Musculoskeletal (M00-M99) ■  Chapter 14 Genitourinary (N00-N99) ■  Chapter 15 Pregnancy & childbirth (O00-O99) ■  Chapter 16 Conditions of perinatal period (P00-P96) ■  Chapter 17 Congenital / Malformations (Q00-Q99) ■  Chapter 18 Signs/Symptoms/abnormal clinical

laboratory findings (R00-R99) ■  Chapter 19 Injury, Poisoning, consequences of external

causes (S00-T88) ■  Chapter 20 External causes of morbidity (V01-Y99)z ■  Chapter 21 Factors influencing health status & contact

with health services (Z00-Z99)

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Chapter 7: Diseases of Eye/Adnexa Detail ■  H00-H05 Eyelid, lacrimal, orbit ■  H10-11 Conjunctiva ■  H15-H22 Sclera, cornea, iris, ciliary body ■  H25-H28 Lens ■  H30-H36 Choroid/retina ■  H40-H42 Glaucoma ■  H43-H44 Vitreous & globe ■  H46-H47 Optic nerve & pathways ■  H49-H52 Ocular muscles, accommodation, refraction ■  H53-H54 Disorders of refraction, Visual disturbances, blindness ■  H55-H57 Other disorders eye & adnexa ■  H59 Intra-operative & post-procedural complications

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Laterality

■  For bilateral sites, final character of code indicates laterality (-1 = R, -2 = L, -3 bilateral)

■  If no bilateral code provided and condition is bilateral –  Assign separate codes for both left and right

■ Ex: –  H43.811 Vitreous degeneration, right side –  H43.812 Vitreous degeneration, left side –  H43.813 Vitreous degeneration, bilateral –  H43.819 Vitreous degeneration, unspecified - Deleted

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Laterality ■ Exceptions are when eyelid coding ■ Ex:

–  H02.011 Cicatricial entropion, right upper lid –  H02.012 Cicatricial entropion, right lower lid –  H02.013 Cicatricial entropion, lid - right unspecified -

Deleted –  H02.014 Cicatricial entropion, left upper –  H02.015 Cicatricial entropion, left lower –  H02.016 Cicatricial entropion, left unspecified lid - Deleted –  H02.019 Cicatricial entropion, unspecified eye, unspecified

lid - Deleted

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Modifier / Laterality Coordination ■  Filing for extended ophthalmoscopy / Drusen

bilateral –  Ex. CPT 92225-RT = H35.361 Drusen, right eye –  Ex. CPT 92225-LT = H35.362 Drusen, left eye –  Some pay on bilateral drusen (H35.363) diagnosis but

most do not and after October 1, 2016 lateral specificity is required

■  Filing for Epilation of misdirected cilia OS, lower lid –  Ex. CPT 67820-E2 = H02.055

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Placeholder Characters ■ Character “X” used as a placeholder

–  Allows for future expansion –  Where it exists it must be used to be valid

■ Ex S05.8x1A –  Some codes will contain more than one placeholder character

■ Ex W31.1xxA

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Placeholder Character Challenges ■ Code extensions (seventh character) have been added for

injuries and consequences of external causes (S00-T88), to identify the encounter –  “A” Initial encounter – receiving “active” treatment

■ Can be used more than once ■ Initial is not always “A” (see radius fracture)

–  “D” Subsequent encounter-use after Pt received active treamt ■ Subsequent not always “D”

–  “S” Sequelae-used for complications/conditions arise as result of injury ■ S only added to injury code, not sequela code ■ Sequela code first, followed by injury code

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7th Character Extension ■ Glaucoma staging by 7th character for severity ■  1 = mild stage (No VFD) ■  2 = moderate stage (1 hemifield VFD) ■  3 = severe stage (both hemifield VFD, or w/in 5 degrees) ■  4 = indeterminate (VF not performed, not reliable etc) ■  0 = unspecified ■ Ex: low tension glaucoma

–  Glaucoma / low tension glaucoma / moderate R, severe L –  H40.-/ H40.12 / H40.121 / H40.1212 –  H40.-/ H40.12 / H40.122 / H40.1223

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Coding for Glaucomas ■ Determine type of glaucoma ■ Determine severity of glaucoma ■ Assign 7th character to stage disease

–  1 - Mild –  2 - Moderate –  3 - Severe –  4 - Indeterminate

■ Ex: pigmentary glaucoma, bilateral / moderate stage –  H40.1332 / H40.1332

■ Ex: pseudoexfoliative glaucoma, left / mild stage –  H40.1421 / H40.1421

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Coding for Glaucomas ■  Primary Open Angle Glaucoma H40.11x__

–  Placeholder replaced with laterality numeral ■ H40.111_ Right eye ■ H40.112_ Left eye ■ H40.113_ Bilateral

–  Add stage code in 7th position to finalize ■ Ex: primary open angle glaucoma, bilateral / mild stage

–  H40.11x1 (old way) –  H40.1131 (New way)

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Additional Glaucoma Code Changes ■  Open angle suspect, Low Risk (1-2 risk factors)

–  H40.011 / -.012 / -.013 ■  Open angle suspect, High Risk (3+ risk factors)

–  Risk factors – family history, race, elevated IOP, disc appearance and thin central corneal thickness

–  H40.021 /-.022 / -.023 ■  Primary angle closure suspect (anatomical suspect, narrow

angle) –  H40.031 / -.032 / -.033

■  Ocular Hypertension –  H40.051 / -.052 / -.053

■  Do not use glaucoma codes that are unspecified! –  Ex. H40.009 and H40.019 - Deleted

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Glaucoma Coding Tips ■  If code includes eye indicator, add stage code for each

eye –  Ex. H40.2232 Angle closure glaucoma, chronic, bilateral,

moderate stage ■  Some glaucoma codes do not require laterality!

–  Unspecified open angle H40.10_ ■ Stage most severely affected eye

–  Unspecified primary angle closure glaucoma H40.20_ ■ Stage most severely affected eye

–  Other unspecified glaucoma H40.89 ■ Stage not used

–  Unspecified glaucoma H40.9 ■ Stage not used

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Glaucoma Coding Tips ■  If no eye indicator, use placeholder x code, add stage for

most severely affected eye –  Ex. H40.10x2 Unspecified open angle glaucoma, moderate

stage ■  Some glaucoma codes do not require staging codes!

–  Ex. H40.211 Acute angle closure glaucoma attack, right eye

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Age Related Macular Degeneration -Dry ■ Old way - No detail or laterality when coding AMD

–  H35.31 Non-exudative AMD –  H35.32 Exudative AMD

■ New Way – add Laterality (6th) & Staging (7th) ■ Laterality – in 6th character

–  -1 Right –  -2 Left –  -3 Both

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Age Related Macular Degeneration-Dry ■ Old way - No detail or laterality when coding AMD

–  H35.31 Non-exudative AMD –  H35.32 Exudative AMD

■ New Way – add Laterality (6th) & Staging (7th) ■  Stage – in 7th character

–  -1 Early –  -2 Intermediate –  -3 Advanced atrophic without subfoveal involvement –  -4 Advanced atrophic with subfoveal involvement

■ Ex: dry AMD, bilateral, intermediate stage –  H35.3132

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AMD - Dry ■ H35.31_1 Nonexud mac degen, early dry stage ■ H35.31_2 Nonexud mac degen, interm dry stage ■ H35.31_3 Nonexud mac degen, adv atrophy w/o

subfov invol ■ H35.31_4 Nonexud mac degen, adv atrophic w

subfov involve ■ H35.31_0 Nonexud mac degen, unspecified

■  In this case the blank space is for the laterality numeral

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Age Related Macular Degeneration-Wet ■ Old way - No detail or laterality when coding AMD

–  H35.32 Exudative AMD ■ New Way – add Laterality (6th) & Staging (7th) ■ Laterality – in 6th character

–  -1 Right –  -2 Left –  -3 Both

■  Stage – 7th character –  -1 Active neovascularization –  -2 Inactive neovascularization –  -3 Inactive scar

■ Ex: AMD, wet, OS, Inactive scar H35.3223

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AMD - Wet ■ H35.32_1 Exud mac degen, w active CNV ■ H35.32_2 Exud mac degen, w inactive CNV ■ H35.32_3 Exud mac degen, inactive scar ■ H35.32_0 Exud mac degen, unspecified

■  In this case the blank space is for the laterality numeral

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Central Retinal Vein Occlusion - CRVO ■ Old way - No detail or laterality when coding CRVO

–  H34.81_ Central retinal vein occlusion ■ New Way – add Laterality (6th) & Staging (7th) ■ Laterality

–  -1 R –  -2 L –  -3 Bilateral

■  Stage – in 7th character –  -0 with macular edema –  -1 with retinal neovascularization –  -2 Stable

■ Ex: CRVO, OD w ME H34.8110

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Branch Retinal Vein Occlusion - BRVO ■ Old way - No detail or laterality when coding BRVO

–  H34.83_ Branch retinal vein occlusion ■ New Way – add Laterality (6th) & Staging (7th) ■ Laterality

–  -1 Right –  -2 Left –  -3 Bilateral

■  Stage – in 7th character –  -0 with macular edema –  -1 with retinal neovascularization –  -2 Stable

■ Ex: BRVO, OS, Stable H34.8322

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CRVO / BRVO Coding ■ H34.81_0 CRVO w ME ■ H34.81_1 CRVO w retinal neovasc ■ H34.81_2 CRVO, stable ■ H34.83_0 BRVO w ME ■ H34.83_1 BRVO w retinal neovasc ■ H34.83_2 BRVO, stable

■  In this case the blank space is for the laterality numeral ■ Note stages start with -0

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Chapter 4: Endocrine, etc ■ Diabetes mellitus

–  Combination codes that include ■ Type of Diabetes / Body system affected ■ Complications affecting body system

–  Sequencing depends on reason for the encounter

■  5 Categories –  E08. Diabetes mellitus due to underlying condition –  E09. Drug or chemical induced diabetes mellitus –  E10. Type 1 diabetes mellitus –  E11. Type 2 diabetes mellitus –  E13. Other specified diabetes mellitus

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Diabetes - Combination Coding ■ Old Way – Type of DM / Type of Retinopathy /

Severity / Edema –  Ex: E11.321 – Type 2 DM with mild, non-proliferative

retinopathy with macular edema

■ New way – Type of DM / Type of Retinopathy / Severity / Edema / Laterality –  Ex: E11.3213 – Type 2 DM with mild, non-proliferative

retinopathy with macular edema, bilateral

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Diabetes – Type 1 Coding NPDR ■ E10.3 __ __ __ ■ E10.3 retinopathy stage, edema, laterality

■  Stage Edema Laterality –  2 Mild -1 with -1 right –  3 Moderate -9 without -2 left –  4 Severe -3 bilateral –  5 PDR

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Diabetes – Type 1 Coding PDR ■ E10.35 __ __ ■ E10.35 PDR stage, laterality

■  Stage Laterality –  2 TRD involv Mac -1 right –  3 TRD not involv Mac -2 left –  4 comb TRD & Rheg RD -3 Bilateral –  5 Stable PDR

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Diabetes – Type 2 Coding NPDR ■ E11.3 __ __ __ ■ E11.3 retinopathy stage, edema, laterality

■  Stage Edema Laterality –  2 Mild -1 with -1 right –  3 Moderate -9 without -2 left –  4 Severe -3 bilateral –  5 PDR

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Diabetes – Type 2 Coding PDR ■ E11.35 __ __ ■ E11.35 PDR stage, laterality

■  Stage Laterality –  2 TRD involv Mac -1 right –  3 TRD not involv Mac -2 left –  4 comb TRD & Rheg RD -3 Bilateral –  5 Stable PDR

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Diabetic Retinopathy Coding Details ■ NPDR – nonproliferative diabetic retinopathy ■ Mild NPDR – microaneurisms only ■ Moderate NPDR – more than mild but less than severe ■  Severe NPDR – no PDR and 2 or more of the

following: severe intraretinal hemorrhages and microaneurisms in each of four quadrants, definite venous bleeding in two or more quadrants, and moderate intraretinal microvascular abnormalities in one or more quadrants

■  PDR – proliferative diabetic retinopathy ■ ME – macular edema

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Chapter 4: Endocrine, etc ■ E11.9 Type 2 DM without complications/retinopathy ■ E10.9 Type 1 DM without complications/retinopathy ■ E10.3392 Type 1 DM with moderate NPDR without

macular edema, left eye ■ E11.3211 Type 2 DM with mild NPDR with macular

edema, right eye AND JUST MAYBE… ■ Z79.4 Long term (current) Use of Insulin (if

documented) –  All Categories except E10 (Type 1 DM) require use of

additional code to identify use of insulin

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Diabetes Type 1 ■ E10.37x_ w ME, resolved following treatment ■ E10.321_ w mild NPDR, w ME ■ E10.329_ w mild NPDR, w/o ME ■ E10.331_ w mod NPDR, w ME ■ E10.339_ w mod NPDR, w/o ME ■ E10.341_ w severe NPDR, w ME ■ E10.349_ w severe NPDR, w/o ME ■ E10.351_ w PDR, w ME ■ E10.352_ w PDR, w TRD involve mac ■ E10.353_ w PDR, w TRD not involve mac

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Diabetes Type 1 ■ E10.354_ w PDR, w comb TRD & Rheg RD ■ E10.355_ w stable PDR ■ E10.359_ w PDR, w/o ME ■ E10.9 w/o mention of complications

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Diabetes Type 2 ■ E11.37x_ w ME, resolved following treatment ■ E11.321_ w mild NPDR, w ME ■ E11.329_ w mild NPDR, w/o ME ■ E11.331_ w mod NPDR, w ME ■ E11.339_ w mod NPDR, w/o ME ■ E11.341_ w severe NPDR, w ME ■ E11.349_ w severe NPDR, w/o ME ■ E11.351_ w PDR, w ME ■ E11.352_ w PDR, w TRD involve mac ■ E11.353_ w PDR, w TRD not involve mac

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Diabetes Type 1 ■ E11.354_ w PDR, w comb TRD & Rheg RD ■ E11.355_ w stable PDR ■ E11.359_ w PDR, w/o ME ■ E11.9 w/o mention of complications

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Confusing Items to Consider ■ Most unspecified codes (ending in -0 or -9) are deleted ■  Stage codes start with -2 in diabetes, start with -0 in vein

occlusions, start w -1 in macular degeneration! ■ Laterality codes are not always in the same position, in

DM it is 7th position, in POAG it is 6th position, vein occlusion it is 6th position, macular degeneration it is 6th position!

■ Don’t forget all these new codes need to be used for PQRS coding (DM, Glaucoma, AMD)!

Monitor Your Accounts Receivables ■  Train all key staff on changes ■  Revise superbills ■  Purchase 2017 ICD-10CM Book ■  Software Updates for PM & EHR

systems immediately ■  Carefully monitor EOBs looking

for denials ■  Watch AR closely in 1st Q ■  Acknowledge positive & negative

variances –  RETRAIN, RETRAIN..

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THANK YOU! ■  Primary Eyecare Network

–  1.800.444.9230 www.primaryeye.net

–  Medicare Compliance Kit ■  Health History Questionnaire ■  Examination Forms ■  E/M Worksheets ■  ICD-10 Codes ■  Interpretation/Report form

–  Medicare A-Z Manual –  CSI’s HIPAA Compliance Manual –  PQRS Card –  ICD-10 Common Diagnosis Card Updated for 2017

Thank you

Excellence in Optometric Education

Missouri Eye Associates

McGreal Educational Institute